Avon Order Form Templates

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					                            AVON BREAST HEALTH OUTREACH PROGRAM

                                   Commonly Asked Questions

This section includes some additional details to assist you in completing your application. It is very
important that you read this section prior to completing and submitting your application.

1.      How do I apply to the Avon Breast Health Outreach Program?
The Avon Foundation for Women has moved to an online application process. All application materials
and attachments must be submitted electronically. The URL to access a new Avon BHOP application
form is https://www.grantrequest.com/SID_1102?SA=SNA&FID=35019. When accessing an
application for the first time you will be prompted to create a grant application account using your email
address as the user id and a password of your choosing. It is imperative that you use your functional
work e-mail address as your log-in e-mail, as that is the address that will be recorded in the system to
receive email correspondence. A tutorial on how to use the online system is posted here.

2.      I previously started an application. How do I log back into my account and continue
        working on the application?
If you have previously created an application account use this URL to go to the account log in page:

3.     When is the application due and how do we confirm that it has been received?
Completed applications and all attachments must be submitted via the online system on or before
Friday, August 27, 2010 by 11:59pm Eastern Time. Extensions will not be granted, and incomplete
applications or those received after the deadline will not be considered. You will receive a confirmation
email shortly after you submit your application to the online system.

4.     What constitutes a complete application?
In order for an application to be considered complete, an applicant will need to submit the following:
            a. Online Application
            b. Program Narrative
            c. Agency Profile
            d. Project Budget-Includes Budget AND Budget Justification Narrative in one document
            e. Medical Provider Commitment Forms (Note that the total number of screenings
                accounted for in the Medical Provider Commitment Forms submitted should correspond
                with the annual screening commitment proposed by your agency.)
            f. Biographies for Key Personnel (No more than two pages per person. Please combine all
                individual biographies into one document for upload)
            g. IRS Letter of Determination for Payee Organization

           In addition, you are welcome to upload:
           h. Letters of Support (optional)

Templates for Program Narrative and Information, Project Budget and Medical Provider
Commitment Forms can be found here.

5.      What are allowable budget items?
Allowable items include support for program staff salaries (the Avon BHOP prefers to support programs
that have a Program Coordinator dedicating the majority of his/her time to the program); program-

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                               AVON BREAST HEALTH OUTREACH PROGRAM

specific supplies (e.g. postcards and postage to mail out reminder and educational materials);
transportation costs for staff; transportation or childcare to enable targeted women to obtain screening
services; and computer and internet service.
Non-allowable items include the cost of medical services, including mammograms and CBEs or salaries
of health care professionals performing these examinations or interpreting results; office furniture and
equipment; medical supplies and equipment; participation in conferences; fund-raising events, and post
treatment support services for women with breast cancer. While the Avon BHOP will allow for a
portion of computer equipment on the budget, the entire amount of the equipment should not be
attributed to the Avon BHOP.

6.      What should be included on the budget / budget justification pages?
Your budget request is based on certain cost assumptions, such as personnel hours projected at a
specified rate, the purchase of a quantity of educational materials at a given unit cost, the use of postage
for an estimated number of mailed pieces, and travel costs for program-specific trips. A well-prepared
budget is one where each line item is explained with detailed assumptions. For example, if you request
$28,600 for personnel-related costs, your assumptions might indicate .75 FTE Program Coordinator X
$15.00/hr X 52 weeks plus .25 FTE clerical support X $10.00/hr X 52 weeks. Similarly, if you request
$4,400 for postage, your assumptions might show 10,000 pieces X $0.44 per piece. On the budget
template - below the budget form - is the Budget Justification Narrative section. Every item that
appears on the budget should be outlined with a short narrative describing the expense item and its function in the
program, the assumptions used to determine the allocation and any further identifying information. A sample
budget and budget justification page is included as Appendix A below. The budget template that should
be filled out and uploaded as an attachment to your application can be found on

7.      What required letters of commitment should be attached?
Confirmation of ability to provide a specific number of free or low-cost screening mammograms and
CBEs must be documented with a description of the number of mammograms and CBEs to be provided
and the cost, if any, to the woman. In addition, information about diagnostic services, such as biopsies,
and treatment services, such as breast surgery or adjuvant therapy, is required and must be documented,
including the number of women for whom the provider is committing to provide follow-up services.

Use the Medical Provider Commitment Form provided as a template to show the level of services that
have been committed to your project. Fill in information about your organization and forward it to all
providers that have committed to providing screening services and/or follow-up care to women you refer
to them. Send with a cover letter, explaining that they (Medical Provider) should fill out the form and
then email it back to your program for inclusion in your grant application. For each provider that has
committed screening and/or follow-up services to your program, please upload a completed Medical
Provider Commitment Form on page 5 of the online application, As all documents must be submitted
via the on line system, you will need to have a digital version of all documents. If you do not have a
scanner available in your office, such capabilities are usually available at your local library or office
supply center or online by utilizing fax-to-email services. If this requirement is a problem for your
organization, please contact Dianne Bal to discuss other solutions at dbal@cicatelli.org.

If you are also receiving in-kind support from your institution, please also provide a letter from a senior
official at your organization confirming the type and value in dollars. (Again, upload on page 5 of the
online application form.)

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                            AVON BREAST HEALTH OUTREACH PROGRAM

8.      Our program works with a large network of providers. We enter into a separate contract
        with each, based on a standard template. Do we need to submit a Medical Provider
        Commitment Form for each one?
If you partner with more than 5 medical providers, you may submit an annotated list of these providers
in place of individual Medical Provider Commitment Forms. For each provider, please specify the
following: 1) provider’s name and full address, 2) dates for which service contract is valid, 3) type of
services to be provided, 4) expected number of women to be serviced, 5) and types of
payment/insurance accepted. In the same document, paste a copy of the standard contract template(s)
used to establish relationships with each provider and upload in place of the Medical Provider
Commitment Form on page 5 of the online application. In addition, please be sure to describe your
program’s relationship with these partners in your Program Narrative.

If the organization partners with a state-wide program which works with a very large number of
providers, applicants should submit a letter from the state agency which details the nature of their
relationship with the agency and guarantees that the screenings will be covered through this program by
one of the many providers.

9.   How do I find out about medical providers in my area that I can partner with?
There are a number of organizations that can direct you to service providers in your area. They include:
       o American Cancer Society’s Breast Cancer Resource Center, 1-800-ACS-2345 or
       o CDC-funded National Breast and Cervical Cancer Early Detection Programs (NBCCEDP),
           which can be reached by calling your state health departments.
       o National Cancer Institute’s Cancer Information Service, 1-800-4-CANCER.
You should also check with your local health department and community hospitals.

10.     What optional letters of support can be attached?
The success of programs often depends upon active community cooperation. Avon encourages a broad
range of partnerships for outreach efforts. Consequently, applicants are encouraged to include letters
from cancer agencies, faith institutions, government health offices, community organizations or other
colleagues that are familiar with your past or proposed programs. If your program forms part of a
coalition/combined effort, include letters from other coalition members/partners describing their role in
and commitment to the joint effort. These letters of support can be uploaded on page 5 of the online
application under the ‘Other Letters of Support’ category.

11.    Proof of Non-Profit Status
To document your Federal non-profit status, attach your non-profit determination letter from the Internal
Revenue Service (this should not be more than three pages). Evidence of State or local tax exemption is
not acceptable. Please do not attach your Federal tax return.

12.     How will grant recipients be selected?
Recommendations for grant recipients will be made by the Avon Breast Health Outreach Program
Coordinating Center based upon the recommendations of a team of independent grant reviewers. The
reviewers are a culturally diverse group of individuals selected from the breast cancer, social service,
medical and corporate sectors. Avon BHOP’s top priority is to fund small community-based
organizations that have access to minority, poor and underserved older women in need of regular breast
cancer screening and follow-up care. In addition, although a higher proportion of funding may be
directed to programs in states with the highest incidence of breast cancer, the Avon BHOP attempts to

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                            AVON BREAST HEALTH OUTREACH PROGRAM

distribute funds throughout the entire U.S. This means that the greater the number of proposals received
from a state, the greater the competition for those applicants. Upon completion of its review process,
the Avon BHOP will submit funding recommendations to the Avon Foundation for Women, which
makes the final funding decisions.

13.     What will the Avon Breast Health Outreach Program Coordinating Center’s role be if my
        program is funded?
The Avon BHOP Coordinating Center staff will be available during the course of the grant period to
provide technical assistance to funded programs over the telephone and through the web site and other
mechanisms. Some onsite technical assistance may be available to selected agencies. Technical
assistance may include, but is not limited to: helping new programs with limited infrastructure with
resources to design and implement their program; helping programs identify and resolve challenges it
may face; offering information or resources for educational materials; reviewing and approving newly-
developed educational materials; providing assistance with evaluation; or suggesting ideas for
recruitment and follow-up strategies.

All funded programs must participate in an initial conference call with representatives from the Avon
BHOP. The purpose of this call will be to review the Program Implementation Guide which includes
useful program information, such as how to publicize program services to the community, obtain free
educational materials, work with medical providers, and utilize evaluation protocols.

The Avon BHOP also provides monthly technical support and informational conference calls.

14.      Our proposed program is part of one division of a large hospital or cancer center. Which
         information should we provide in the Background section?
For this question, the Avon BHOP would like to see information about the larger organization and the
relationship between your program and this organization. First, give a brief overview of your parent
institution (e.g. hospital/cancer center/university), followed by more detailed information about the
division (e.g. Breast Cancer/Oncology/ Outreach) of which your proposed program will be a part.
Please also provide strategies and affiliations as appropriate. You will have an opportunity to provide
detailed information specifically about your program in the ‘project description / abstract’ field.

15.     What data reporting will be required?
All funded projects will be expected to provide progress reports every three months throughout the one-
year project period. In addition, for each client receiving screening services through Avon BHOP
projects, the agency must submit a completed Client Intake Form [Appendix B below]. These forms are
sent to the Avon BHOP Coordinating Center where they are scanned into a database. Those agencies
that already collect this information and have it available on their data systems may submit the
information electronically to the Avon BHOP Coordinating Center once a data transfer arrangement has
been made. The use of the reporting forms will be reviewed on a project start-up conference call at the
beginning of the project period.

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                              AVON BREAST HEALTH OUTREACH PROGRAM

                                               APPENDIX A
                                 SAMPLE BUDGET: Breast Health Program
                                  January 1, 2011 to December 31, 2011
                                 ASSUMPTIONS                   AVON         *Other         Agency In-   Total Budget
                                                              Request       Fund             kind
                                                                A               B              C          A+B+C
 Director, Women's         0.2 FTE @ $25/hr x 52                      $0              $0     $10,400         $10,400
 Services                  weeks
 Coordinator, Breast       0.75 FTE @ $15/hr x 52                23,400                0           0          23,400
 Health Program            weeks
 Outreach Workers          2 workers - each 0.5 FTE @                   0      10,400         10,400          20,800
                           $10hr x 52 weeks
   Subtotal Personnel                                            23,400        10,400         20,800          54,600
 Fringe @ 23%                                                     5,382         2,392          4,784          12,558
   Sub-total                                                    $28,782       $12,792        $25,584         $67,158

Other than Personnel
   Client transportation   80 bus rides @ $3/roundtrip               240               0           0             240
  Outreach worker local    $0.31 x 100 miles per week x              806          806              0           1,612
  transportation           52 weeks
 Teaching Materials
  ACS materials            2000 pieces @ $1.50 each                 3,000              0           0           3,000
  Breast models            2 @ $150/model                             300              0           0             300
 Printing/Advertising                                                                  0           0               0
  Flyers                   printing of 2000 @                        100               0           0             100
   Newspaper ads           7 @ $200/ad                              1,000         400              0           1,400
   Radio PSAs                                                           0           0              0               0
   Printing of CIFs        500 2-sided pieces @ $0.20                 100
   Postcard printing       2000 pieces @ $0.10 each                   200              0           0             200
   Postage                 2000 pieces @ $0.44/piece                  880              0           0             820
 Child care                150 hours @ $7/hr                        1,050              0           0           1,050
 Dedicated program         $75/month x 12 months                      900              0           0             900
 Modem and Internet                                                     0              0           0               0
   Sub-total                                                     $8,576        $1,206             $0          $9,782
   Personnel & OTPS                                             $37,358       $13,998        $25,584         $76,940
Indirect expenses                                                $3,736               $0      $3,958          $7,694

   TOTAL                                                        $41,114       $13,998        $29,542         $84,654

* Other Secured Funding Sources: For example, Susan G. Komen Foundation, United Way, etc.

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                               AVON BREAST HEALTH OUTREACH PROGRAM

                          Instructions for BUDGET                JUSTIFICATION

*This portion of the budget submission gets entered in the space provided directly below the budget form in the
excel document and should list every item that appears on the budget page with a short narrative describing the
expense item and its function in the program, the assumptions used to determine the allocation and any further
identifying information.

Please note: Excel cells will only hold approximately 1,000 characters of text before they will no longer wrap
the text. If the text does not wrap, it will run past the right margin of the cell and will not be easily visible. To
ensure reviewers will be able to read your justification, please only put 1,000 characters or less in each text cell.
You can type directly into the cells or copy and paste from MS Word.

List every individual on payroll with FTE (Full Time Employee) and salary requirements. Include short
description of program responsibilities and reporting lines if appropriate.
Fringe Benefits - identify organization’s fringe benefit rate and any variance for individual employees if

Other Than Personnel Services
Transportation - projected expenses, explain the need for transportation funds, type of transportation to
be used (private car mileage rate, public transportation fares, etc.), the number of trips to be subsidized
and which personnel will be using these funds.
Teaching Materials – include a short discussion on the materials to be purchased, how they will be used
and the expenses to be incurred for each category of material (printed brochures, anatomy models, etc.).
Printing /Advertising – For each category of printing and/or advertising listing in the budget include a
description of the item, its use and the specific associated cost. Grantees are responsible for printing
their own CIFs.
Example: Flyers- will be used to advertise program activities, to be posted on public bulletin boards, and
distributed to individual during outreach activities. Budget allocation covers the expenses of printing 2000 copies
at .10 each.
Child Care - Include the reason for this expense (for example that child care will increase attendance and
follow-up at appointments, etc.), the number of hours to be covered by this allocation and how that
number was determined. Include who will be responsible for distributing these funds and how records
will be maintained.
Telephone – List actual expense of telephone for the Avon project. If a dedicated line is used, include
the actual expense for that line (installation, monthly charges, etc.) or use a formula similar to:
Formula example: Number of Avon FTEs divided by Total Program personnel = % Avon dedicated
personnel (i.e. 2.5 FTE’s in Avon / 12 Total program personnel = 20%)
Total cost of telephone service multiplied by percentage of staff on Avon project = cost to Avon project.
(i.e. $800/year X 20% Avon expense = $160 Avon Expense)
Modem & Internet Service – If an AVON dedicated line exists, list actual expense. If necessary, use
telephone formula to identify Avon portion of total expense. Describe choice of method of allocation of
Indirect Expense: Identify indirect cost rate and how it was developed, i.e. federally authorized rate,
based on actual direct expenses (say what expenses are included in “direct expenses”, rate determined by
parent or sponsoring organizations, etc.). Cannot exceed 10% of the project budget.

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             Appendix B

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